“Controversial award-winning sociologist Timmermans … looks at the work of medical examiners in this intriguing study. … The portrait emerging from the author's study of the important social role MEs play is a useful corrective to the media-inspired image of the all-knowing and perfect CSI technicians. … Timmermans's detailed look at the notorious Louise Woodward "nanny trial" and other topical subjects (such as organ donation) make this a must-read for anyone interested in learning what postmortems really involve.”—Publishers Weekly

An excerpt from

Postmortem

How Medical Examiners Explain Suspicious Deaths

Stefan Timmermans

Introduction
Brokering Suspicious Deaths

Death is not an individual but a social event. When, with a barely noticeable sigh, the last gasp of air is exhaled, the blood stops pulsating through arteries and veins, and neurons cease activating the brain, the life of a human organism has ended. Death is not official, however, until the community takes notice. In modern societies, a physician—any physician will do—verifies that death has occurred, often by simply putting a stethoscope on the chest to listen for heart sounds and palpating for a pulse. Except in cases of organ procurement, the last medical act consists of filling out a death certificate, where the physician notes the time and cause of death.

Death work is routinized in three sequences, each with a different orientation: an implicit focus on death avoidance during life, a dignified dying experience, and a clean, quick disposal after death. As one of the first and most influential works of medical sociology explained, societies function on the premise that people do not get sick, and if they do get sick, it is their responsibility to get better. Talcott Parsons’s "sick role" could be extended to a "death role." It is everyone’s responsibility to keep on living. The health care system operates from a negative orientation: the traditional emphasis is not necessarily to promote wellness and health, but to minimize physical deterioration and complications among those already ill. Death is the outcome to be avoided. Statistically, a country’s bill of health is measured in infant mortality, life expectancy, leading causes of death, and potential productive years lost. The postponement of death permeates every aspect of health care but is particularly well manifested in the omnipresence of resuscitation technologies in intensive-care units and emergency departments.

When in spite of all intentions and aggressive treatments death is inevitable, the interaction at the deathbed is reversed. With 75 percent of U.S. deaths taking place in hospitals or nursing homes, most deaths occur as routines in well-prepared places, surrounded by specialized staff who manage culturally appropriate passings. The transition from cure to care might be made hours, days, or months before death occurs and is a consequence of an inoperable, incurable deterioration in an illness trajectory. Elisabeth Kübler-Ross’s influential books on the psychodynamic acceptance of pending death paved the way for conformity in light of mortality and carved out a space for spiritual and religious guidance. In near unison, patients, relatives, and health care providers report that they envision a "good" death as occurring with pain and symptoms under control, conscious decision making at the end, time to prepare for death, spiritual closure, an opportunity to reciprocate to others, and affirmation of the whole person. New groups of specialists, including palliative-care physicians, cater to this cultural model by offering terminal care in hospices. Stringent right-to-die initiatives are gaining momentum. The emphasis is on maintaining autonomy for the patient while mining the medicine cabinet to ease pain and suffering.

Once death has occurred, medicine relinquishes any claims for further intervention (again, with the notable exception of organ and tissue procurement). The attending physician certifies death by noting the time and a cause of death, which is usually the patient’s primary diagnosis. The corpse is transferred to a funeral director, who takes care of embalming, wakes, and funerals according to laws and religious customs. A good disposal is a quick and clean event, celebrating the memory of the deceased.

The contradictory attitudes of death avoidance and acceptance are resolved in light of medical history and age. When old age has been reached or physicians have declared that a cure is unavailable, not only is death sanctioned, but one is also expected to accept death. Even when it is unfathomable for relatives and friends, most deaths make medical sense: a diabetic patient was known to have had bad coronary arteries; a nursing home resident had been treated for advanced liver carcinomas; a child died after a lengthy bout with lymphoma; emergency-department staff noticed a heart attack in progress on the EKG monitor of a middle-aged woman and were unable to reverse the process. The medical history links an individual’s death to the big natural killers: heart disease, cancer, stroke, and infectious diseases. The pattern softens the inevitability of the passing. Death is not a random event but due to a chronic or progressive process that ravaged vital organs. For old people, a death of natural causes is tolerated in light of life’s achievements and the physical decline and suffering associated with aging. Even without a strong medical history, the elderly are expected to live with the possibility of pending death.

When deaths fall outside this interpretive medical spectrum, however, the social order of dying is disturbed. About 20 percent of people die in suspicious circumstances, meaning out of place and time. The social institutions and professionals taking care of the dying did not anticipate the death, which generates an anomalous, potentially threatening situation. Suspicious death raises the possibility of a public health danger. Did the itchy rash and flu-like symptoms mask an anthrax infection? Was a traumatic death due to criminal activity? After an unexpected death, rumors are rife about who might benefit financially or emotionally, casting doubt on the sincerity of the grievers. Sometimes it is not the manner of death that is questionable but the identity of the deceased. Who should be notified when an unidentified body is found? Because of the tight medical control surrounding most terminal events, death becomes suspicious not only when crime is involved, but also when the passing escapes a medical prognosis: when people die without medical records, when they die unexpectedly under medical care, or when they die because of trauma in a medical setting. The danger of a suspicious death resides in the possibility that more such victims will be claimed. To investigate the risk and uncertainty of suspicious death, another kind of death worker—a coroner or a medical examiner—toils in a morgue. These professionals are part of an invisible public health and criminal justice infrastructure whose sole task is to investigate suspicious deaths.

Social scientists, health care providers, and bioethicists have extensively studied the emergence of hospice care, right-to-die initiatives, and aggressive lifesaving interventions in order to evaluate the quality of the contemporary dying experience. Deaths that escape close medical management, however, have received attention only summarily. The lack of critical scrutiny is remarkable, because death investigators enact a relationship to death different from that of the clinician. In contrast with common health care interventions, death investigators’ work is guided not by cure or care—avoiding death or preparing for the final transition—but by the need to generate expert knowledge about life. Determining the cause and manner of suspicious deaths is highly technical work, dependent on scene investigation findings, autopsy observations, toxicology test values, and a close reading of medical files. This expert work necessarily has a strong cultural dimension, because it involves locating corpses in contested categories of death. This book, based on three years of observation in a medical examiner’s office, looks at the daily work of death investigators as a cultural instance of managing lethal risk, uncertainty, and danger.

The Replacement of Coroners with Medical Examiners

Coroners have traditionally conducted death investigations and still serve about half of the U.S. population. Their mandate dates back to the twelfth century, when officers collected money owed to the English Crown and were known as "crowners" or "keepers of the pleas of the crown." Coroners had broad powers to hold inquests, hear confessions in sanctuaries, grant pardons, seize treasure, confiscate royal fishes (whales, sturgeons, and porpoises), and investigate shipwrecks. Medieval coroners’ rolls show, however, that they were engaged mostly with inquests into suicide and homicide. The investigation of death carried consequences. Suicide was a crime against God and king that resulted in forfeiture of the victim’s estate. Accidental deaths caused by a moving inanimate object (e.g., a well, horse cart, or mill wheel) entailed forfeiture of the object. Coroners held inquests in public places after viewing the corpse and questioning witnesses so that the jury could render a verdict.

In the nineteenth century, the position of coroner in the United States was part of the patronage and spoils system of municipal government. Coroners were not judges but had the authority of committing magistrates, and they could make arrests and set bail for prisoners. In spite of their legal authority, coroners often had little legal knowledge; some lacked even basic literacy skills. Coroners initially operated on a fee-for-service basis, receiving payment at each inquest. In New York City, at the turn of the twentieth century, they first became salaried. Regardless of the form of remuneration, bribes and embezzlement in coroners’ offices were legion, because coroners had great leeway in presenting evidence and steering a verdict in a desired direction. Politicians were put on the payroll of businesses attempting to avoid bad publicity or liability when deaths occurred because of safety violations. These politicians served as "fixers": for a fee, they tried to influence the coroner’s court by picking the jury members, paying off the coroner or district attorney, condoning perjury, or sending key witnesses out of state. Similarly, well-connected families paid for suicides to be classified as accidents and unsavory details to be suppressed. George LeBrun, secretary to the New York coroner’s and later medical examiner’s office from 1898 until his retirement in the 1940s (and himself a political appointee) reported that the success of businesses and individuals depended on the corruption of the coroner: "A few of the coroners, and let me emphasize that it were only a few, were outrageous crooks who dispensed ‘justice’ for cash. Their only interest in each new case was to discover how they could extort money, and they used the power of their office for blackmail purposes." Even uncorrupted coroners would manipulate the usual procedures of the death investigation system when a politician asked for a favor to protect a family against the stigma of suicide. When the determination of suicide was straightforward, for example, no inquest would be held, allowing the coroner to file the death certificate days later—escaping the attention of reporters, who checked only the new cases.

Coroners are now public officials, appointed or elected. They do not necessarily have medical backgrounds or training in death investigation. They may still, however, hold inquests before juries to determine the manner of death. For example, the coroner of McLean County, Illinois, may call an inquest in front of six citizens of the county. The inquest is open to the public, and the jurors determine the manner of death (suicide, accident, homicide, natural death, or undetermined death) on the basis of the information presented. Coroners may employ physicians to perform autopsies and technicians to conduct toxicology testing. In some counties, anyone can become a coroner, so that the post has been held by tow-truck drivers, paramedics, plumbers, bar owners, nurses, carpenters, police officers, and funeral directors. Coroners still run death investigations in counties and districts of eleven U.S. states. In an attempt to professionalize their trade, some counties have required coroners to meet stricter education requirements (including basic medical or legal training) and obtain certification in programs offered by the American Board of Medicolegal Death Investigators. Eighteen states now have a mix of coroner and medical examiner systems, and medical examiners are the sole death investigators in twenty-two states, practicing on a state, county, or district level. Medical examiners began to replace coroners in 1877, in Massachusetts, but most systems switched between 1955 and 1985. The shift to a medical examiner then stalled in the mid-1980s. At the beginning of the twenty-first century, about half of the U.S. population is served by coroners and the other half by medical examiners. There are more than two thousand death investigation jurisdictions, most at the county level.

The switch to a medical examiner system entails an expansion of scientific power and a curtailing of political power. All states with medical examiners require them to be physicians, and most demand additional certification in anatomical and forensic pathology. Medical examiners do not preside over a jury inquest but base their conclusions largely on a scene investigation, medical files, an autopsy, and laboratory tests. All inquiries take place behind closed doors, out of the public eye. Although the police are in charge of the crime scene, medical examiners have jurisdiction over the corpse and can request paraphernalia found at the crime scene that might shed light on the death. Medical examiners are charged with identifying the body and determining the cause and manner of death. The cause of death is "a disease, abnormality, injury, or poisoning that contributed directly or indirectly to death," perhaps cerebral hemorrhage, asphyxiation, severe pulmonary congestion and edema, or sudden infant death syndrome. Five categories constitute the possibilities for the manner of death: natural, accident, suicide, homicide, and undetermined. The forensic manner of death is not legally binding for law enforcement or prosecution but is a crucial part of fact-finding in criminal investigations.

The replacement of coroners with medical examiners is a milestone in the long history of growing medical authority over death. George LeBrun, who witnessed the transition from the coroner’s court to the medical examiner’s office of New York City in 1918, noted the difference in the quality of the death investigation when the scrupulous Dr. Charles Norris, a professor of pathology at Columbia University medical school and director of the Bellevue Hospital laboratories, became the first medical examiner. Appalled by the lack of understanding of gunshot wounds, Dr. Norris and his assistants fired all kinds of guns into different materials from various ranges and angles, studied the gunpowder marks and shot patterns, and then applied this knowledge to cases. Dr. Norris’s superior professional knowledge became apparent when he disagreed with a former coroner’s physician (who was now working in law enforcement) and successfully established that a death previously considered a suicide was actually a homicide; in another case, Dr. Norris changed an apparent homicide to a suicide.

According to LeBrun, not only corruption but also legislative initiative disappeared with the coroner’s court. When the coroner’s inquest worked well, it was a perfect vehicle for bringing awareness of dangerous situations into the public realm and instituting reforms. In the heyday of the New York City coroner’s office, the politically savvy coroner’s court was at the forefront in requiring elevator safety devices, advocating for the replacement of open streetcars discharging passengers in the middle of the street with buses that pulled up to the curb, requiring poisons to be labeled as such, fighting for driver’s licenses, and spearheading one of the first gun-control laws, the Sullivan law. LeBrun attributed the coroner’s power to his privileged position and to the open character of the inquest, which led to well-cultivated contacts with politicians and reporters. The early New York City medical examiner’s office still had the power to call public inquests, but Dr. Norris never used that privilege, preferring that the district attorney take the lead.

Forensic Authority

This book addresses the cultural trade-off created by placing suspicious death under the jurisdiction of the most professionalized of death investigators: medical examiners trained as forensic pathologists. Medical examiners fill out death certificates on the basis of scientific expertise, but their work is never simply about documenting the results from toxicology, histology, or pathology. Rather, they must reconcile deeply held moral values with the pathological signs of the body. Mediating between the corpse and the modern world, medical examiners make cultural connections for us. The work in the medical examiner’s office starts from the assumption that the corpse harbors the secrets of its demise and that the death investigator’s task is to reveal this knowledge for the public good. Much as we rely on insurance brokers to explain the arcane issues of insurance, we depend on medical examiners to be society’s brokers of suspicious death: expert intermediaries who negotiate and establish the meaning of violent and suspicious deaths. Medical examiners determine what makes a death a suicide or what qualifies as abuse in the death of an infant. They aim to bring rational, scientific order by explaining the seemingly unexplainable. This cultural service, however, is far from obvious. Pathologists’ expertise is based on the shape and function of diseased tissues and organs. Why would we expect these practitioners to solve the puzzle of suspicious mortality and to illuminate the risks of living in late modern societies? Why would we believe them?

Indeed, the cultural power of death investigators is often contested. Sociologist Eric Klinenberg, for example, gives an account of the conflict about documenting the number of heat-related deaths in Chicago during the scorching summer of 1995. Cook County’s medical examiner began to classify deaths as heat-related. Chicago’s mayor disagreed with the classification, arguing that a heat wave was a naturally recurring event in a city of extreme temperatures and that the vulnerable city dwellers in the morgue would have died anyway. When the tally of excess heat deaths grew to 739 within one week, several refrigerator trucks had to be brought in to store the bodies—dramatically underscoring the magnitude of this true disaster. Other forensic experts and public health officials then rallied around the medical examiner, and the mayor ceased to question the medical examiner’s determinations. Why had the mayor contested the classification? The political stakes of attributing deaths to a disaster are high for city leaders. A previous Chicago mayor had lost his job in part because of his administration’s inability to handle a snowstorm. The public believes that if deaths can be attributed to severe weather, they might be preventable, and city government can be held accountable. Even where the circumstances are less dramatic, any death investigation might be contested, and previous allies might turn against medical examiners.

At the heart of this book is the question of the professional and cultural authority of medical examiners, which I will refer to as forensic authority. Professional authority is the legitimacy accorded to an occupational group to conduct professional work and have its judgments accepted by various audiences. The professional authority of clinicians, for example, lies in their ability to convince patients to follow recommended interventions based on a process of diagnosis and in their ability to receive reimbursement and recognition for their work from third parties. For medical examiners, professional authority encompasses the ways they investigate deaths and have each determination accepted as valid. Medical examiners’ professional authority is reflected in the selection and investigation of cases, as well as the acceptance of their conclusions by relatives, public health officials, and law enforcement officers. As Paul Starr has pointed out, professional authority may involve cultural authority when professionals are also able to establish the definition of things. Cultural authority is the "probability that particular definitions of reality and judgments of meaning and value will prevail as valid and true." For medical examiners, cultural authority lies in their ability to shape the understanding of relatives and other audiences about what suspicious death is. Forensic authority thus means not only establishing what caused a specific death according to professional standards (through professional authority), but also defining what suicide or homicide is about (through cultural authority). Medical examiners may have professional authority with little cultural authority if they conduct their investigations within the conceptions of death defined by others.

Forensic authority determines what medical examiners can and will decide. Scientific and lay notions of suspicious death are common understandings riddled with inconsistencies and exceptions. Take suicide. In an often-quoted formulation, the World Health Organization defines suicide as "a suicidal act with a fatal outcome" and a suicidal act as "self injury with varying degrees of lethal intent." Working from this definition, the eminent suicide researcher Edwin Shneidman devoted an entire book to defining suicide and concluded, "Currently in the Western world, suicide is a conscious act of self-induced annihilation, best understood as a multidimensional malaise in a needful individual who defines an issue for which the suicide is perceived as the best solution." Although useful for suicide prevention and scholarship, these definitions have little value for forensic investigations. How do you recognize "lethal intent," "a conscious act" resulting from "multidimensional malaise," "a needful individual," or "the best solution" in a corpse? When faced with a dead body and some traces of a spent life, how can a pathologist establish that a man intended to take his own life? Was the "I love you. Take care" scribbled on a gum wrapper a clumsy expression of love or a short suicide note? Did the fifteen-year-old girl miscount sleeping pills or intend to end her life? In spite of the ambiguity of suicide, forensic pathologists have to make definitive judgments about the value of evidence and intent.

Forensic authority consists in the reputation of the entire profession of medical examiners and reflects on individual practitioners’ credibility, integrity, and legitimacy, their investigative procedures, and their conclusions drawn from forensic evidence. Every forensic pathologist in training gradually accumulates credibility from credentials, a broad variety of autopsy experiences, exchanges with others, and courtroom testimonies. The pathologist does not have to establish credibility from scratch: the authority invested in a community of medical examiners with similar training, credentials, and experiences serves as a reference for individual credibility. An individual medical examiner making blunders might lose credibility and so be unable to fulfill the task of death brokering, but the forensic authority of medical examiners need not be tarnished by a single wayward practitioner. Someone else will fill the position. Similarly, telegenic "star" medical examiners might develop reputations that surpass the authority of medical examiners as a group. Professional vulnerability would develop if the loss of forensic authority of medical examiners as a whole began to reduce the credibility of individual pathologists. In an example from another area of forensics, fingerprinting experts recently risked losing professional and cultural authority with legal challenges to their scientific credentials. With authority lost, even the most skilled or experienced fingerprinting expert might as well be reading tea leaves; every individual fingerprint identification lacks credibility.

When medical examiners classify deaths as heat-related, they have forensic authority if the deaths are considered by relevant authorities to have been caused by excessive heat, which was indeed acknowledged in the Chicago heat wave of 1995. In the aftermath of the dispute between the mayor and the medical examiner, the Centers for Disease Control and Prevention (CDC) launched a study of the heat-wave victims in Chicago and alerted death investigators around the country about new facts on fatal heat exhaustion. These actions validated the authority of medical examiners as a professional group to recognize and classify these deaths. Maintaining forensic authority does not necessarily require that relatives and other parties agree with forensic classifications. Medical examiners lack coercive powers to enforce their determinations; instead, they offer official opinions. Forensic authority implies the surrender of private for expert judgment, even if forensic conclusions run counter to someone’s financial interests, religious beliefs, or other deeply held values. A groundswell of criticism arising against medical examiners’ classification of suicide, for example, might diminish cultural authority, especially if other parties (such as police officers or forensic psychiatrists) take over these investigations. When forensic authority is unquestioned, however, audiences are compelled to accept medical examiners’ conclusions, and their determinations carry implications for courts, insurance agencies, and other institutions.

Forensic authority is a measure of successful death brokering, a gauge of medical examiners’ ability to conduct their work and have their determinations accepted as true and valid. In our justice and public health systems, the forensic specialist’s close scrutiny of corpses for signs of abuse and causes of death seems inevitable. How would we otherwise be able to detect the next lethal epidemic? How could we have homicide investigations without white-coated experts looking for signs of injury? Who would detect the next anthrax epidemic or alert us to the dangers of unsafe children’s toys? The authority of death investigators seems rock-solid. A need for expertise, however, does not guarantee that forensic pathologists are or will remain the most appropriate specialists to inquire about death. The shaky fate of the once-authoritative fingerprinting experts is instructive here. And even if medical examiners are the preferred investigators, the deaths they investigate and the conclusions they draw may remain contested. Medical examiners could be reduced to technicians who simply process evidence for others to consider, exercising little or no cultural authority of their own. More often than disgruntled mayors, lawyers routinely contest medical examiners’ forensic authority, especially when criminal cases hinge on the processing and interpretation of evidence. Rather than being rock-solid, the authority of a profession fluctuates and can decline suddenly.